Sunday, March 4, 2007

Asperger's and Alexithymia

“We now have a psychological term, alexithymia, to describe another characteristic associated with Asperger’s syndrome… Clinical experience and research have confirmed that alexithymia can be recognized in the profile of abilities of people with Asperger’s syndrome.” [Tony Attwood]

Ongoing research has revealed a significant overlap between alexithymia [definition] and autistic spectrum disorders (ASD's). Two recent studies25 suggest that individuals with ASD exhibit a higher degree of alexithymia than matched control participants, with 85% of the participants with ASD showing slight or severe alexithymic impairment. This raises the important questions for future research regarding how to explain the high co-morbidity of alexithymia and ASD, and from a clinical perspective the finding suggests that a diagnosis of ASD should be considered in patients with alexithymia.

[This] overlap may be applicable for Asperger's syndrome, which has similarities with alexithymic behaviour that have long been recognized. Every well known AS measure reflects the centrality of alexithymic phenomena in its diagnostic criteria: e.g. Lack of social or emotional reciprocity (DSM-IV), Impaired or deviant response to other people's emotions (ICD-10), Difficulty sensing feelings of others (Szatmari criteria), Difficulties expressing themselves, especially when talking about emotions (NAS definition), Emotionally inappropriate behaviour… Impairment of comprehension (Gillberg criteria).

Like all alexithymic persons, AS individuals have difficulty understanding their own and others' emotional arousal along with problems expressing feelings with verbal and nonverbal behaviour or in reading that of others, which correlate with the alexithymic subtraits: (a) difficulty identifying feelings and distinguishing between feelings and bodily sensations of emotional arousal, and (b) difficulty describing feelings to other people. In AS there is also a limited imagination, an absence of symbolic thinking, and a preoccupation with factual information which traits correlate with the alexithymic: (c) constricted imaginal processes, as evidenced by a paucity of fantasies, and; (d) a stimulus-bound, externally oriented cognitive style. The syndromes also share a propensity for psychosomatic disorders and hypochondriacal features26

Similarities noted, there are further distinguishing traits marking Asperger’s syndrome such as the tendency toward mild autistic behaviours like 'stereotyped and repetitive motor mannerisms such as hand or finger flapping or twisting, or complex whole-body movements'27 which are not features of simple alexithymia, and secondly, whilst AS individuals are with few exceptions alexithymic they have added difficulties in reading the objective, non-emotional intentions of others' minds. This mind-reading or ‘Theory of Mind’ (ToM) is the ability individuals may or may not possess for understanding and interpreting the mindset of another person, where the observer predicts the thoughts of the target individual by placing him or herself in their position and simulating the actions or beliefs of the target individual. Whilst a lack of ToM is central to Asperger’s syndrome, a recent study has shown that this is not a deficiency integral to uncomplicated alexithymia.28 This study selected forty-five high alexithymic subjects to undertake a 'false belief task' which involved a picture-sequencing task of four cartoon-style cards focussing on beliefs of an objective kind that did not require the identification of an emotional component. The task gauged their ability to read the thoughts of others based on the available cues. Alexithymic subjects were able to correctly complete the task, sometimes performing better than samples from a group of non-alexithymic subjects who completed the task, leading to the conclusion that alexithymic individuals possessed a Theory of Mind. At present ToM measures do not gauge ability or inability to recognise discrete emotions, meaning it does not adequately distinguish between alexithymic and non-alexithymic traits; its aim is purely to measure an individual’s ability to read the objective thought patterns of other people.

Individuals with uncomplicated or ‘simple’ alexithymia are more socially adaptive than AS individuals principally because they have a Theory of Mind allowing a degree of social competence, but problems arise when they are faced with situations where intimacy is required. Alexithymics may develop the ability to interpret and navigate the social world by applying logical rules about the beliefs and behaviours of other people but cannot articulate the emotional nuances which are intertwined with these interpersonal beliefs, i.e. they are able to anticipate and interact with others so as to form functional, but not feelings-based intimacies.

As well as mild autistic behaviours and mind-blindness, alexithymia constitutes a core factor of Asperger's syndrome as it is presently conceived. While this has not been strongly recognised in the past, it is becoming increasingly clear that the alexithymia construct is the most accurate, scientifically validated measure for gauging the emotional ‘differences’ inherent to Asperger’s syndrome. As remarked by a leading AS researcher Tony Atwood: “We now have a psychological term, alexithymia, to describe another characteristic associated with Asperger’s syndrome, namely someone who has an impaired ability to identify and describe feeling states. Clinical experience and research have confirmed that alexithymia can be recognized in the profile of abilities of people with Asperger’s syndrome…”29

[Excerpted from 'Blocked Imagination~ Emptied Speech' – by Jason Thompson]


References

25. E. Hill, S. Berthoz, & U. Frith, 'Journal of Autism and Developmental Disorders' 34, 229-235 (2004) and; S. Berthoz, & E. Hill, 'European Psychiatry' 20, 291-298 (2005)

26. Michael Fitzgerald & Guy Molyneux- The overlap between Alexithymia and Asperger's Syndrome. Letter to the Editor; American Journal of Psychiatry 161, 2134-2135, (2004)

27. Diagnostic and Statistical Manual (DSM-IV) criteria 299.80 Asperger's Disorder- (B: 4)

28. Colin A. Wastell, Alan J. Taylor- Alexithymic mentalising: Theory of mind and social adaptation. Social Behavior and Personality, (2002)

29. Tony Attwood- The Complete Guide to Asperger's Syndrome (2005)



For a slightly improved, updated version of the above article, see the book below:

Emotionally Dumb: An Overview of Alexithymia (1) - Kindle Edition - Kindle Book (July 16, 2009) by Jason Thompson
Buy: $5.25
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Alexithymia and Asperger syndrome
[Alexitimia y síndrome de Asperger – translated from Spanish].

Isabel Paula-Pérez, Juan Martos-Pérez, María Llorente-Comí.

[Rev Neurol 2010, 50 (Suppl. 3): S85-S90]

[PMID: 20200852 - Presentation - Publication Date: 03/03/2010]

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Introduction: The study starts with the hypothesis that the difficulty in identifying and describing emotions and feelings, and distinguishing the feelings of bodily sensations that accompany them, are a common denominator in the constructs of alexithymia and Asperger syndrome (AS).

Patients and methods: The study evaluates the levels of alexithymia in nine males with AS.

Apparatus and procedure: We used the following scales and questionnaires (with the sample we also used other instruments not included in current study): Toronto Alexithymia Scale (TAS-20) The TAS was developed by Bagby et al [6] has two validations: the Moral de la Rubia and Retana [7] and Martinez-Sanchez [8]. Alexithymia scale for observers (OAS) has been used in various publications, for example, Haviland et al [10] and was translated directly from its original source. Online Alexithymia Questionnaire (OAQ-G2) The OAQ-G2 was developed in 2005 by Thompson [9] in response to perceived limitations in other existing alexithymia questionnaires, and was translated by A JJ Ordinas and R. Nogués.

Results: With the TAS-20, 5 subjects (55%) obtained a score indicating the presence of alexithymia, 1 subject (11%) obtained a score that suggests possible alexithymia, and in 3 cases (34%) the score indicates absence of alexithymia. That is, with this instrument, two thirds of subjects had alexithymia. With the OAQ-G2, 3 subjects (34%) obtained a score indicating a clear presence of alexithymia, 4 patients (44%) obtained a score that suggests possible alexithymia, and in 2 subjects (22%) the score indicates absence of alexithymia. With this instrument and adding the first two groups of people, three-quarters of the subjects had or may have alexithymia.

Discussion: The research reveals an overlap between alexithymia and AS. The data obtained in the sample agree with those obtained by Hill et al [12], who found that 85% of people with AS showed a moderate or severe alexithymia. The global analysis of data prompts a differentiation of results according to whether the source of information is the subject itself with AS (TAS-20 and OAQ-G2) or if the source is a relative who lives with the person with AS (OAS). In the first case, the data are significant but not conclusive: two thirds of patients with AS have or may alexithymia, according to the TAS-20 and three quarters have or may alexithymia, according to the OAQ-G2. However, when it comes to assessing the levels of alexithymia by the family, the data are crucial, doubling the score in the neurotypical population.

The study results are very significant when it comes to assessing the levels of alexithymia in patients with AS by people living with them, their families. These are those who experience daily the impact it has on their interpersonal relationships of family: little warmth in the relationship, difficulty feeling compassion, little tenderness, stiffness in everyday life, confusion to stress, frustration in dealing with uncertainty, little sense of humor, etc. The prospective research invites the question of how to explain the high comorbidity between alexithymia and AS. Is alexithymia a neuroanatomical structural consequence or is the result of a neurobiological impairment, or is it rather an idiosyncratic personality trait of individuals with AS? If so, would alexithymia therefore be a useful diagnostic criterion for the AS? Not surprisingly, the diagnostic criteria covers various aspects of alexithymia: 'lack of social and emotional reciprocity' (DSM-IV-TR) [5], '); ‘impaired or deviant response to other people’s emotions' (ICD -10) [16], 'difficulty expressing themselves, especially when talking about emotions' (definition of the National Autistic Society) [17], emotionally inappropriate behaviour… impairment of comprehension (Gillberg diagnostic criteria) [18] ... As it says Attwood [19], 'we now have a psychological term, alexithymia to describe other characteristics associated with AS, ie someone who has an impaired ability to identify and describe emotional states. Clinical experience and research have confirmed that alexithymia can be recognized in the skills and profile of people with AS. "

Conclusion: Based on the adults studied a significant comorbidity was confirmed between alexithymia and AS, leading to the question of whether alexithymia is an idiosyncratic feature of subjects with AS.

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